DKA Flashcards
what are the diagnostic criteria for DKA?
glucose >11
pH <7.3 or bicarb <15
ketones >3 in blood or 2+ or more in urine
what is DKA a complication of?
T1DM or rarely T2DM
what are the different severities for DKA?
mild: pH <7.3, bicarb <15, 5% dehydrated
moderate: ph <7.2, bicarb <10, 5% dehydrated
severe: pH <7.1, bicarb <5, 10% dehydrated
why is it important to frequently check an insulin pump?
if an insulin pump stops working for 8-10 hours they can go into DKA
what are some potential causes/triggers of DKA?
infection
cessation of insulin/inadequate insulin
CVD eg stroke, MI
drugs eg steroids, thiazides, SGLT2s
recreational drugs eg cocaine, MDMA
what are the clinical features of DKA?
polyuria
polydipsia
vomiting
dehydration
altered mental state
coma
weakness
lethargy
kussmaul respiration
acetone breath smell
what is kussmaul breathing?
deep, rapid, and labored breathing at a consistent pace
what are the bedside investigations for DKA?
classic A-E-look for cause, infection, etc
cap BM-v high
urine dip -ketone ++, glucose +ve
12 lead ECG -?MI, monitor for arrhythmias
what are the blood tests for DKA?
plasma glucose -high
FBC -?infection
CRP -?infection
U+E
plasma osmolality
cardiac enzymes -?MI
ck -?rhabdo
amylase -?pancreatitis
blood cultures -?sepsis
VBG
what would you see in U+Es of DKA?
Na+ may ne high due to dehydration or low due to sugar pulling water +Na+ out of cells
K+ may be high due to acidosis, normal, or low
urea and creatinien may be raised due to dehydration and potentially AKI
what is the plasma osmolality in DKA?
> 290
what does the VBG for DKA show?
metabolic acidosis
low pH
low HC03-
anion gap usually >13
>16 shows v severe DKA
how do you work out anion gap?
positive ions -negative ions (Na+ +K+) -(Cl- -HC03-)
what blood ketone level would signify severe DKA?
> 6
what are the main treatment points of DKA?
IV fluids and electrolyte replacement if needed
insulin
regular monitoring
treat underlying cause
what is the IV fluid treatment in DKA?
follow trust guidelines but:
initial wide bore cannula and bolus resuscitation with 0/9% saline
then maintenance fluids:
0.9% saline 1L over 1 hour
then you can add potassium (KCl) if needed
if glucose falls to less than 14, give 10% glucose at 125ml/h alongside the other fluids
what do the different potassium levels mean in DKA?
> 5.5: don’t give potassium
3.5-5.5: give 40mmol/L of KCl
<3.5: senior review
how should you manage insulin in DKA?
fixed rate IV insulin infusion (FRIII) -50 units made up to 50ml with 0.9% NaCl, infuse at fixed rate of 0.1U/kg/h
need to wait an 1-2h before giving in kids!
continue the FRIII until ketones <0.6, pH >7.3, HC03- >18.
never stop their normal long acting insulin!
how do you monitor a patient with DKA?
measure BMs and cap ketones hourly
VBG at 60min and 2h after and every 2h after that
what is the difference in DKA management in paeds?
give 02
different fluids
need to wait to give insulin
check pee before giving K+
monitor closely for cerebral oedema
what is the fluid treatment for DKA in paeds?
if not shocked: 10ml/kg NaCl over 60 min
if shocked: 10ml/kg NaCl over 5-10min, repeat to max of 4x before calling PICU if still shocked
after 1st hour can add potassium 40mmol/L KCl to fluid
only add KCl if K+ <5.5 and child can pee/wet nappy
add 5% dextrose if BM <14
what is the insulin treatment for kids with DKA?
1-2 hours post fluids, start FRIII 0.05-0.1U/kg/h. absolute no to give before 1h post fluids-risk of cerebral oedema
what are the targets for how fast ketones and bicarb should be changing in DKA management?
ketones -decreasing by 0.5mmol/h
bicarb -increasing by 3mmol/h
what are the criteria for an episode of DKA to be resolved?
glucose >11.1
bicarb >18
pH >7.3
anion gap <10
